Worth Reading: Vaccine Refusal and Hookworm Economics

Hey Liz, I'm so glad you enjoyed the hookworm article! Thank you so much for sharing it with your readers.

In Maryn McKenna's article, What vaccine refusal really costs: Measles in Arizona, I think that the key sentence is this one:

"a 37-year-old Swiss woman who had never been vaccinated against measles arrived in Tucson after a visit to Mexico. "

Whatever the issues were for this individual woman, this seems to me to be a potential problem! Demographically speaking, women of childbearing age ought to be fully immunized with the MMR, given that congenital rubella syndrome can cause very serious problems or death.

Back before the vaccine was developed, many parents deliberately exposed their children to mumps and rubella, not because this was risk free, but because the diseases were seen as inevitable and risks of contracting these diseases as adults was seen as so much greater. In this case it was children that were intended to provide the herd immunity for the adults. Other diseases such as Whooping cough, are not as much an issue in adults as they are in children, and it is the adults that need to provide herd immunity for small infants. The infants at risk are frequently too young to be immunized. Thus, it seems to me that the importance of ensuring that adults are immunized and maintain their immunity needs to be more fully realized. This is especially true for those that provide a cocoon of care around infants.

It is not clear to me that vaccine refusal was the major issue here. The original journal article, http://jid.oxfordjournals.org/content/early/2011/04/25/infdis.jir115.ab…, concludes: "Suspecting measles as a diagnosis, instituting immediate airborne isolation, and ensuring rapidly retrievable measles immunity records for HCPs are paramount in preventing health careâassociated spread and in minimizing hospital outbreakâresponse costs. " The journal article points out that: "HCP (Health care professionals) measles immunity data from 2 hospitals confirmed that 1776 (25%) of 7195 HCP lacked evidence of measles immunity."

The fact that these problems exist is all the more reason that everyone should be vaccinated, and ensure that their own children are vaccinated. However, from a public health perspective, is our tendency to focus blame on vaccine refusers causing us to neglect other systemic matters for which all of us should be held responsible?

Gaythia, I was also struck by the sentence about the number of healthcare professionals lacking evidence of measles immunity. I don't know whether the lack of evidence of immunity was due to deliberate vaccine refusal or to an oversight (I'm not sure I could produce my own complete record of vaccinations), but I think the important message is that inadequate vaccination has huge costs. Vaccine refusers are probably the most visible, determined, and growing factor in inadequate vaccination coverage.

In his "Why Patients are Not Consumers" article, Krugman asks aloud:

"How did it become normal, or for that matter even acceptable, to refer to medical patients as "consumers"? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car â and their only complaint is that it isnât commercial enough."

It happened when it became necessary for patients, particularly those with chronic conditions, to doctor-shop to find someone who knows what theyâre doing, is interested in helping and is willing to do what it takes. In an earlier time, I believe this was known as âwork.â Unfortunately, I cannot definitively state exactly when (apparently this was before I got âoldâ and started consuming (whoops! âpatientingâ(?)) medical care) or how this happened, though Iâm sure the usual suspects will blame their respective hobby-horses.

I think this is Krugman's key paragraph about why it's problematic to view patients as consumers, as though consuming healthcare were like consuming food or entertainment:

Medical care, after all, is an area in which crucial decisions â life and death decisions â must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

I liked Shadowfax's post on the same issue because he writes not only as a doctor but also as someone who faced exactly the kinds of challenges Krugman describes - having to rely on another doctor's specialized knowledge under stressful, time-pressed conditions - when his wife was diagnosed with breast cancer. And, since he doesn't have the print-publication word limit, he's able to go into more detail about how being a patient is different from being a consumer of other goods and services.

In that context, a patient is a subset of consumer. But for the majority of your life, you're not (I hope) going to be under the stress of immediate life-threatening conditions. Most of the time, you're a consumer making decisions about your health care all along the way.

I think that one's perspective here is going to depend on one's access to health care professionals, and the amount of choice one has in selecting these individuals and facilities.

People in small towns go to whoever has been wiling to stay in practice there. People without insurance might have access to public clinic, one of those 24 hour care centers or might head to the nearest hospital emergency room. People with health insurance may have had 5 plans to chose from, or no choice at all. Some people go to whoever there HMO has hired, and may or may not have choices, depending on the size of the facility at their location. Some people better have family available to help navigate if they are incapacitated because their insurance may not cover them if they land in the wrong medical facility or are seen by an unapproved specialist.

So, some people may handle their choices as consumers, trying for the best cost/benefit outcome, and some may just resign themselves to taking whatever comes. I think that people at the top of the health insurance pyramid may not realize that others would have a very hard time achieving health care where they felt that their care met the standard described by Krugmen, where: "The relationship between patient and doctor used to be considered something special, almost sacred." (which may not have been true in the past, either.)

"I think that people at the top of the health insurance pyramid may not realize that others would have a very hard time achieving health care where they felt that their care met the standard described by Krugmen"

Likely they have no idea. I don't think Krugman's hurting for cash -- he probably gets any specialist he needs out-of-pocket.